[Is this the end for double RAAS inhibition?].

Recently, the VA NEPHRON-D study was stopped early due to insignificant effects and increased adverse events. This was the last in a series of trials on the value of dual versus single blockade of the renin-angiotensin-aldosterone system in patients at risk for renal or cardiovascular complications. From these studies, the picture has emerged that dual blockade is hardly effective and increases the risk of hyperkalaemia and renal failure. Background use of beta blockers - little recognised indirect renin inhibitors - may play a role in the detrimental effects of dual blockade. Aldosterone antagonists in combination with one of the RAAS inhibitors may confer some benefit, but have not been studied sufficiently. For now, combining ACE inhibitors, angiotensin receptor blockers and aliskiren is to be discouraged.